This 2012 file photo of a cesarean birth offers some perspective of the daunting challenges of operating on newborns and other tiny patients. (AP Photo/Felipe Dana)

Dr. Steven Rothenberg, pediatric surgeon and chair of surgery at Rocky Mountain Hospital for Children in Denver has received a national award given to physicians whose work has significantly transformed the field of endoscopy and minimally invasive surgery.

The Society of American Gastrointestinal and Endoscopic Surgeons honored Rothenberg as the 2015 “SAGES Pioneer in Surgical Endoscopy” on April 15 in Nashville.

Recipients are recognized as “pioneering surgeons who developed new surgical techniques, created innovative instruments or have fostered the growth of minimally invasive surgery through mentoring and clinical education,” hospital officials said.

Rothenberg has performed many of the first pediatric surgeries in the world using endoscopic or minimally-invasive techniques involving thin tubes attached to cameras and other instruments. The techniques require much smaller incisions and inflict much less trauma to the body.

Although SAGES primarily focuses on advancing and developing less-invasive surgical techniques in adults, Rothenberg joined SAGES 20 years ago while working with a group of pediatric surgeons to develop the International Pediatric Surgery Group. He has helped bring the two groups together to collaborate on surgical advancements.

He performed the first thoracoscopic repair of a tracheo-esophageal atresia in a newborn. It’s a congenital defect in which, in most cases, the upper esophagus ends without connecting with the lower esophagus and stomach — the top end of the lower esophagus connects instead to the windpipe.

Rothenberg performed the first thoracoscopic lobectomy in a child in the world — using a specially outfitted tube to remove a portion of lung.

And he performed the first repair in a U.S. infant of duodenal atresia — a common intestinal anomaly.

Rothenberg, a professor of surgery at Columbia University in New York, trains other surgeons throughout the country and also teaches extensively internationally.

Rothenberg has worked with National Jewish Health in Denver to study the relationship between gastric reflux (GERD) and reactive airway disease in children.

In this March 31, 2014 file photo, Michelle Decker, left, an employee of Connect For Health Colorado, the state’s health insurance exchange, explains options and procedures to a walk in client signing up for insurance on the last day before fines were imposed, in Denver. IT and online enrollment glitches plagued thousands of consumers during 2015 open enrollment.(AP Photo/Brennan Linsley)

The legislative oversight committee for the state health insurance exchange heard Wednesday from brokers, agents and consumers about the good, the bad and the ugly aspects of the two-year-old marketplace.

Even as the oversight committee heard testimony from some of those directly affected by operational problems and successes at the exchange, the Senate passed a bill allowing the committee to change its name and to meet 10 times after the legislative session ends.

The new name will be the Colorado Health Insurance Exchange Oversight Committee – only slightly less of a mouthful than the current Legislative Health Benefit Exchange Implementation Review Committee.

“We’re seeking the unvarnished truth,” said the committee, chair Sen. Ellen Roberts, R-Durango. Roberts has promised greater scrutiny of the exchange by the committee.

Ben Price, director of the Colorado Association of Health Plans, opened by saying the exchange was very important to carriers, who wanted a marketplace where consumers could really compare what was available to them.

“We’re two years in, and it’s been a success, but it hasn’t always been a pretty success,” Price said. “There are still many, many technical challenges. From a carrier’s perspective, we’re at a critical juncture.”

More than 140,000 Coloradans have been insured, he said, and the marketplace here is very competitive – with 12 major carriers while states with comparable populations have only two or three.

Fixes to the exchanges online enrollment system – its Shared Eligibility System with Medicaid – must be done quickly and right to avoid the bottleneck created during the most recent enrollment, Price said.

“It has delayed people’s coverage for months,” he said.

Tammy Niederman with the Colorado State Association of Health Underwriters said brokers provided the exchange with about 40 percent of the business done.

Niederman said that simple changes to people’s policies – such as adding a new baby, changing an address – that were once readily effected are now difficult. And many people were inadvertently terminated.

“The carrier is not getting feeds in a timely manner,” she said. “These are very simple things, right? Things that were once easy to accomplish have now turned into extremely stressful situations (for clients).”

Debra Judy with the Colorado Consumer Health Initiative said the ranks of the uninsured have shrunk, and they have heard many success stories of consumers getting critical coverage at reasonable rates. Yet, she said, the enrollment process must get simpler to use and correct.

All three groups praised hard-working staff at Connect for Health Colorado, but commented that staff size was too small to get the job done.

AURORA, CO – Dec. 10: Crews stand outside of the partial complete hospital buildings while cleaning up the worksite Wednesday, December 10, 2014 at the new Veteran Administrator hospital in Aurora, Colorado. The contractor, Kiewit-Turner, walked away from the construction site after the VA breached its contract by making a design that goes over the original budget of $604 million. (Photo By Brent Lewis/The Denver Post)

Just down the road from the roughly half-completed Aurora VA hospital, labeled by congressional leaders as the biggest construction debacle in the department’s dicey history, another medical campus of comparable scale has emerged a lauded success.

At the University of Colorado Hospital, like the VA site, construction has dragged out for more than a decade, with costs rising to $1 billion and beyond.

Yet the path of the two medical campuses diverges there. At the VA site, a $600 million budget and estimated completion date of early 2014 has swollen and stretched to roughly $1.73 billion – don’t get too attached to this number – with opening maybe in 2017, maybe not.

“You bite off chunks of the elephant. You don’t try to eat it all at once,” Menogan said. “We built our outpatient facilities. We then built inpatient facilities. We could then move our entire campus to the new site in 2007. We just did it in phases instead of building a billion-dollar project all at once.”

They are slightly under that price tag at the moment. That’s every cost – bed sheets to garages – with close to a new total of 591 licensed inpatient beds ready in the next month or so, UCH spokesman Dan Weaver said. They anticipate having closer to 700 beds being used in the foreseeable future. The total square footage is 4.1 million – minus garages it is 2.75 million square feet.

The VA’s 1.1 million square-foot replacement facility, if completed as planned, will have 182 beds.

The old, rough rule of thumb is that, when construction costs supporting medical care of inpatients are divided by the number of hospital beds, the cost per bed should be between $1 million to $2 million.

At UCH, Menogan says that the two inpatient towers cost $694 million, which means each of 661 beds is calculated to cost $1,049,000 per bed.

If you add in the construction costs of the UCH cancer center, stand-along emergency department, eye center, parking garages, conference center and all the features of a leading medical campus, it’s closer to $1.7 million a bed. Menogan argues that’s not the right formula, yet the figure still falls in the $1 million to $2 million window.
Using this same lump-sum approach, the cost per bed at the VA hospital, for which itemized costs aren’t available, would be about $9.5 million.

At the VA’s planned 1.1 million square-foot facility, where the veterans arguably require a different set of services – and apparently more outpatient than inpatient – the construction costs for the inpatient building and other structures most directly supporting the 182 beds are either not known or not available. A more refined calculation isn’t possible, and contractor Kiewit-Turner didn’t respond for a Denver Post request for an alternative figure. K-T has limited its remarks because of its ongoing negotiations with the VA and the Army Corps of Engineers, which recently has taken over managing the struggling project.

Construction of UCH’s newest 12-story patient tower was done in a swift – some say record – 22 months, finishing in early 2013. General contractor Haselden Construction Inc. used prefabricated elements, such as pre-built bathrooms, to speed up the work.

Prefabricated elements increased efficiency at the new 365-bed St. Joseph Hospital at the corner of 19th Avenue and Downing Street, a congested work zone hemmed in by a bustling city.

Planning for St. Joseph’s 831,321 square feet started in 2010 and total project cost was $623 million. SCL Health opened it in December.

Hospital specialties are heart care, cancer treatment, innovative women and infant facilities, respiratory care, orthopedics and emergency services. They don’t come cheaply. Applying the same crude calculation using the total construction price, the cost per bed was $1.7 million.

After fewer than two years of construction, St. Anthony’s North Health Campus was opened by Centura Health in Westminster March 3. The 350,000 square-foot build cost $177 million.

Joshua Montoya on his 5th birthday with his Children’s Hospital Colorado Heart Institute doctors, Scott Auerbach and Max Mitchell. Montoya was airlifted in November 2013 from Albuquerque, NM to Children’s Colorado, where he spent months in the hospital connected to a Berlin heart pump before receiving a heart transplant in mid-June. He just went home to New Mexico Sept. 16. The ACE Kids Act will help kids with complex medical needs, like Montoya’s, to cross state lines to access specialized care (Photo courtesy of Children’s Hospital Colorado).

UPDATE: The U.S. Senate on March 24 adopted an amendment introduced by Sens. Michael Bennet, D-Colo., and Rob Portman, R-Ohio, to improve care for children with medically complex conditions who rely on Medicaid.

The Advancing Care for Exceptional Kids Act would allow health care providers to deliver services to kids with these complicated conditions through models that coordinate care between providers, improving results and lowering costs, Bennet said in a press release.

SEPT. 17, 2014
Children prematurely born and those with cancer, congenital heart disease, cystic fibrosis, Down syndrome and other complicated medical conditions have lifelong challenges that proposed federal legislation would try to make more manageable for families.

About two-thirds of the 3 million U.S. children with complex cases are covered by Medicaid. They make up only 6 percent of Medicaid child enrollees, yet they account for almost 40 percent of Medicaid costs for children, said Children’s Hospital Colorado chief executive Jim Shmerling.

Advances in health care have made it possible for many more of these children to survive these conditions. Yet many must first go from doctor to doctor to find answers and effective treatments. They often must leave their home states to get the specialized care they require at regional centers.

The proposed Advancing Care for Exceptional Kids Act of 2014, or ACE Kids, would provide for the creation of voluntary nationally designated children’s hospital networks to coordinate care for children with complex illnesses and disorders. Based on health needs and family preference, each child would be matched with a network anchored by a children’s hospital — it would help both families and providers across state lines, proponents say.

“These children receive fragmented care from multiple providers and duplicated tests, Shmerling said. “It’s a very expensive fragmented system. We need to reshape the delivery of their care.”

Bill supporters, which began with 10 children’s hospitals and now includes more than 60 hospitals, point to two commissioned actuarial studies showing the coordinated system they propose could cut Medicaid costs by 2 percent, saving $10 billion to $13 billion a year.

“This is certainly not a grab for market share,” he said. “It improves care and reduces costs.”

The Troop family from Bountiful, Utah, has adopted six children. Four of them have a rare connective-tissue disorder called epidermolysis bullosa, or EB, with skin so fragile that almost any friction or impact can cause blisters, wounds and scarring. It’s the same with the mucosal tissue lining their mouths, throats, eyes and affects organs.

Christy Mahon, 34, of Denver, became the first woman ever to ski all of Colorado’s 54 fourteeners. Christy is pictured hiking the steep East Face on her way to the top of 14,025 ft Pyramid Peak oon May 8th 2010, the 47th highest mountain peak in Colorado, and 78th highest peak in U.S. It is located in the Elk Mountains in southeastern Pitkin County. Photo by Ted Mahon, Special to the Denver Post

People in Colorado’s mountain communities are living the dream, at least according to a new ranking of counties based on quality of life and length of life.

The 2015 County Health Rankings, a program of the Robert Wood Johnson Foundation released March 25, identify Colorado’s healthiest counties based on factors from tobacco use and exercise to access to high-quality care — using the latest available data.

Pitkin County is ranked first. It is joined at the top 10 by several mountain counties and a couple of plains representatives. Denver County placed a dismal 40th. In the metro area, Douglas and Boulder came out on top, in part because healthy outcomes are tied to income and education levels.

Rural counties in the sate’s southeast rural, less-developed region generally are at the lower end, including Conejos, Las Animas, Costilla and Huerfano counties.

Overall, Colorado compares well with national statistics in areas such as years lost to “premature death” (before age 75) — Coloradans have better longevity — and smoking — 21 percent of U.S adults smoke, compared with 17 percent across Colorado.

However, Coloradans overall have poorer air and drinking water quality compared with national averages, the study says. And Coloradans, on average, are more at risk for violent crime. In the U.S, there are 11.9 incidences per 100,000 population. In Colorado, it’s 12.7 incidences. By county, the violent crime rate varies from 10 incidences to 13.8 per 100,000.

Published online at countyhealthrankings.org, the rankings are meant to help counties understand what influences longevity and well being.

“The rankings are unique in their ability to measure the current overall health of each county in all 50 states. They also look at a variety of measures that affect the future health of communities, such as high school graduation rates, access to healthy foods, rates of smoking, obesity, and teen births.”

The rankings’ creators advise communities use the rankings to find support for local health improvement initiatives among government agencies, healthcare providers, community organizations, business leaders, policy makers and the public.

Three major US tobacco companies — Philip Morris, RJ Reynolds and Lorillard –in 2012 agreed to pay $100 million to settle more than 400 lawsuits claiming that smoking damaged people’s health, but since then new harms associated with smoking continue to be identified. ( AFP PHOTO/PAUL J. RICHARDSPAUL J. RICHARDS/AFP/Getty Images)

Current guidelines don’t recommend screening for osteoporosis in men, but a large study of middle-aged to elderly smokers found that men were more likely than women to have low bone density and fractures of their vertebrae.

COPD is the third-leading cause of death in the U.S., where almost half the population 45 and older is a smoker or ex-smoker.

“Our findings suggest that current and past smokers of both genders should be screened for osteoporosis,” said Dr. Elizabeth Regan, assistant professor of medicine at National Jewish Health. “Expanding screening to include men with a smoking history and starting treatment in those with bone disease may prevent fractures, improve quality of life and reduce health care costs.”

Researchers from National Jewish Health and other institutions, studied 3,321 smokers and former smokers ages 45-80 with a minimum of 10 pack-years history ( A pack year is defined as twenty cigarettes smoked every day for one year).

About 11 percent of participants had normal bone density; 31 percent had intermediate density and 58 percent had low bone density. And 37 percent of those evaluated had one or more fractures of their vertebrae.

Men made up 55 percent of the smokers with low bone density and 60 percent of those with vertebral fractures.

Researchers further found that as subjects’ COPD worsened, the prevalence of low bone density increased, rising to 84 percent among severe COPD patients, whichever the gender.

Those with low bone density had a smoking history of an average of 46.9 pack-years.

During a conference in Aurora, Rabbi Levi Brackman, right, speaks with Jonathan Ely, 15, left, a freshman at Smoky Hill, and his mother Jeanne Symonds, middle, about the Youth DIrections mentoring program.

Youth Directions, a Denver-area nonprofit, is offering teenagers an opportunity to gain ten hours of free coaching to help them discover a career-focused purpose in life as part of a research study.

The coaching also aims to help teens make long-term passionate goals, including decisions about college attendance and majors.

“Research over the last 10 years has shown that purposeful youth are much more likely to succeed and flourish in almost every domain, psychologically, academically and physically,” Youth Directions founder Levi Brackman said. “A lack of purpose conversely is a predictor of many negative outcomes in youth.”

Youth Directions has spent the last six years developing an evidence-based coaching program that fosters purpose in teens. The program, “Purpose Navigator,” is now undergoing intensive research by a group of psychologists and social scientists from the United States and Australia to test the degree to which it fosters both purpose and other elements of well-being in youth.

“We are committed to subjecting our Purpose Navigator coaching to rigorous scientific testing and are therefore offering $800 worth of coaching free of charge to youth who are willing to be part of our study,” Brackman said.

The intensive group coaching sessions led by Brackman will take place in the Metro Denver area over spring break and summer vacation. There is space for 100 participants. Other researchers include Professor Herbert W. Marsh and Dr. Phil Parker of the Institute for Positive Psychology and Education based in Sydney, Australia.

Teens who are interested in being part of the study and therefore gaining purpose coaching for no charge can sign up here: http://goo.gl/FBnJ8s, or email Levi Brackman for further information at l.brackman@youthdirections.org. Or call 303-462-5777.

Medicaid patients enrolling through the state health insurance exchange are taking too much of its time and resources, exchange board members said Monday, but Medicaid officials propose an even tighter partnership with a single technology vendor.

The federal policy of “no wrong door” was meant to be a single online portal for the uninsured that would seamlessly determine their eligibility for either Medicaid or private insurance with tax subsidies. But system and user errors have caused thousands of Colorado customers seeking financial assistance under the Affordable Care Act to get stuck mid-enrollment.

The online Shared Eligibility System — the interface between the state marketplace and Medicaid — has caused most of the intractable problems, exchange officials say.

Although open enrollment for 2015 health plans officially ended Feb. 15, at least 700 people are still hung up in the system — down from a peak of 10,000 complaints, according to Connect for Health Colorado’s enrollment report, released Monday at the exchange board meeting.

Before technology glitches can be fixed, exchange board members said, they must resolve a key policy question about the mission and brand of the state’s independent nonprofit marketplace. How aligned or entangled should it become with the much-larger Medicaid system administered through Colorado Department of Health Care Policy and Financing.

Exchange interim chief executive Gary Drews said the board must decide to “ either take on the face of Medicaid and change our brand,” or find another solution.

“Every day that goes by we’re feeling the pressure of not working on these things,” Drews said. “We do know we have a vast portion of our resources going to Medicaid. (Should we) put people in the hands of folks whose core competencies are Medicaid?”

Discussions between Health Care Policy and Financing and Connect for Health Colorado will be watched by the governor’s office.

“The governor is interested in making sure that there is an appropriate level of collaboration … and that we get the right people talking about this,” said David Padrino, Gov. John Hickenlooper’s deputy chief of staff. He declined to say the governor’s office would mediate any dispute.

Exchange staff estimate that Medicaid customers made 40 percent to 45 percent of calls to the customer service center, for which the forecast 2014-15 budget has climbed from just less than the the $15 million approved by the board to about $21 million.

“The Medicaid expansion has cost us significantly more than we thought,” said board member Dr. Mike Fallon. “We need paying customers to become financially stable. The customers of Connect for Health are paying to support Medicaid. We don’t have the money to do this. Our $26 million dollar (annual operating) budget is now laughable.”

Health Care Policy and Financing executive director Sue Birch said the data the exchange offered on costs attributable to Medicaid enrollees was “primitive.”

“What I don’t think is being heard is that Medicaid will pay its fair share once it gets that (better) data,” said Birch, who is also a non-voting member of the exchange board.

Drews and others said exchange workers don’t have full access to information in the Medicaid system, the Colorado Benefits-Management System, which makes it difficult for the exchange to help households caught between the two systems.

The board voted Monday to seek proposals for an independent end-to-end review of the technology systems, while moving ahead with obvious tech fixes and deciding the larger issue of the exchange’s involvement in Medicaid.

Only 54 percent of 2015 enrollees received financial assistance. The other 46 percent didn’t have to navigate the eligibility system.

One proposed technology fix is that customers who are clearly not Medicaid-eligible get shunted along an expedited pathway toward tax credits, bypassing the shared eligibility system Cost estimates range from $2 million to $7 million.

Another option is an even more integrated system with Medicaid, which Fallon said he opposed.

“We become a small cog in a huge machine we have no control over,” Fallon said. “I encourage the board to do minimum interoperability with Medicaid.”

Of the total 224,171 applications for financial assistance submitted through the Shared Eligibility System during the recent three-month open enrollment period, 76,783 applications originated from Connect for Health Colorado, the exchange reported. An estimated 78 percent of marketplace customers who went through the Shared Eligibility System received a “real-time” (roughly an hour) eligibility determination. About 52,000 were denied Medicaid and were sent to the marketplace eligible for financial subsidies toward their private insurance plans.

Birch said board members were overlooking the “extraordinary successes” of the exchange-Medicaid partnership to date.

“Our reason for existing is to help people who need insurance,” Birch said.

Broker John Luhman said during public comment that he disagreed with the exchange estimates of enrollees still shut out of coverage.

“You’re telling me there are 700 people left out there. I’m telling you you’re wrong,” Luhman said. “I have 38 households hung up.”

Luhman is one of 1,300 brokers working with the exchange.

“I’m afraid of my customers going though this ungodly process over and over,” he said. “You have a system of technology that’s horrible. It stinks.”

A Swedish Medical Center team was part of a clinical trial involving six U.S. stroke centers that found a clot-retrieval procedure inside the artery dramatically improves patient outcomes after stroke.

A report published Feb. 12 in the New England Journal of Medicine said the clinical trial confirms that a clot-retrieval procedure known as endovascular treatment (ET) reduced the overall mortality rate from two in 10 patients to one in 10 patients suffering from an acute ischemic stroke — sudden loss of blood to an area of the brain because of a large clot blocking an artery.

“This clinical trial proves beyond any doubt that inside the artery therapy is the best possible treatment for patients suffering from an acute ischemic stroke from a large artery occlusion,” neurosurgeon Dr. Donald Frei said in a statement released Thursday by the medical center in Englewood.

“ET is performed by inserting a thin tube into the artery in the groinm through the body and into the brain vessels to the clot,” Swedish officials explained. It’s done using an X-ray to produce an image that guides the tube. The clot is pulled out, which restores blood flow to the brain.

“The vast majority of our patients benefit from ET, but the key factor is time,” Frei said. “The patient’s best chance for an independent outcome is to get to a comprehensive stroke center as fast as possible.”

Physician salaries vary widely by specialty and state, but there are also marked differences from county to county.

An internal medicine physician in Denver making an average $215,000 a year could make, on average, $33,000 a year more by moving to Boulder. She or he could make, on average, $55,000 more a year moving to Cheyenne County, which has the state-high average at $270,000. It can pay to move to a rural area, but not always. In Rio Blanco County, the average annual salary is $184,000.

It also can pay to move to a smaller city. High-cost areas actually often pay lower physician salaries. Denver internal medicine salaries, while just slightly below national averages, are more than averages in New York, Los Angeles and Boston — not adjusted for cost of living in any way. In Boston, a leading metropolitan hub of medical education, an internist’s averages salary is only $202,000 a year.

Salt Lake City’s average for internal medicine is $232,000 a year. In the Phoenix area, it’s $243,000.

The figures are from the Doximity medical professional network. At the end of January, Doximity launched a tool called Career Navigator, an interactive salary map, for member doctors to track local trends in pay.

General trends in pay include: Physicians working in private practice make an estimated 12 precent more than those working in academic or government institutions.

The Medscape Physician Compensation Report 2014 shows again that orthopedists are the top earners, with average annual pay of $413,000, followed by cardiologists, and with urologists and gastroenterologists tied for third. The lowest earners are primary care physicians and endocrinologists.

Those who perform procedures, Medscape notes, have the highest incomes compared with those who manage chronic illnesses.

Major physician shortages exist in family medicine, emergency medicine, occupational medicine and psychiatry.

Electa Draper is the health writer for The Denver Post and has covered every news beat in a 22-year journalism career at three newspapers. She has a bachelor's degree in biology and a master's in journalism.